The number of men entering the nursing profession is slowly increasing, with current estimates showing that, depending on the region, men make up 5–25% of the nursing workforce (World Health Organization, 2020: 36). However, there still remains the social and engendered stigma associated with male nurses that often prevents men from contemplating a nursing career (Kouta and Kaite, 2011; Clow et al, 2014). The male nursing figure is still portrayed as being effeminate, homosexual or a sexual predator (Allison et al, 2004; Harding, 2007; Christensen, 2017). Combined with the notion that men are unable to provide the type of nurturing care only a woman can provide (Loughrey, 2008), this means that male nurturing is often confined to those areas where technical prowess takes precedence over direct patient contact (Harris, 2012). This may be seen as a sweeping generalisation, yet there is higher incidence of male nurses working in the intensive care unit, accident and emergency departments or operating theatres than aged care, palliative care or community nursing (Harris, 2012).
The reasons for this may be multifactorial. However, it has been suggested that this may about the nature of male care and caring. Milligan (2001), for example, suggested that male nurse care tended to focus predominately on the biophysical needs of the patient and the that emotional/psychological aspects of care were more attuned to problem-solving (caring for) and not necessarily what Entwhistle (2004) saw as ‘caring about’, ie empathy, presented as something female nurses can do intuitively. Likewise, Paterson et al's (1995) earlier work identified that therapeutic touch for male nurses was viewed as one of those skills to be learnt, unlike their female colleagues where it apparently came naturally. Interestingly, Miller (2004) described male nursing care in terms of an efficient-competency aspect—nursing care being delivered in a task-focused manner, ‘getting the job done’ to alleviate a patient's physical discomfort.
Although the literature is packed with reports of hidden advantages and the expressed pitfalls of being a male nurse in a female-dominated profession, there is a growing body of research identifying similar experiences among male nursing students (Miller, 2004; Wood, 2004). Undoubtedly, nursing is seen as a non-traditional career path for men and it is for this reason that men entering into preregistration nursing programmes tend to be older, with nursing being their second or third career (Boughn, 2001). Work around the experiences of male nursing students has identified similar barriers to those of their registered colleagues: feelings of isolation, being taken advantage of and questions as to their motives for wanting to be a nurse (Anthony, 2004; Mohammed, 2012). For example, in Christensen and Knight's (2015: 100) thematic analysis of male nursing student experiences one student commented that ‘I have been told on a number of occasions that nursing is no place for men’. Likewise, O'Lynn's (2004) work in using the Inventory of Male Friendliness in Nursing Programs (n=111) found that both the clinical and educational environment were outwardly unwelcoming of male students (92%) and more distressing was the overt anti-male remarks made by nursing academics towards male nurses (89%). More recently, respondents in Christensen's (2017) phenomenological study were critical that their experiences of the nursing programme left them feeling labelled, exposed, excluded and vulnerable. Outside the classroom, clinical practice also imposed challenges for male nursing students. In Sedgwick and Kellett's (2015) study, for example, respondents scored higher on the Belongingness Scale for clinical placement experiences for statements associated with feelings of isolation: ‘I feel discriminated against in placements’ and ‘I feel like an outsider’.
Negativity aside, men embarking in a career in nursing see the nursing profession offering them financial stability and security, opportunities for career progression and variety, and included within this is wanting to care. Undoubtedly, there has been some significant work looking specifically at the nature of male nurse caring, for example, the work of Paterson et al (1995), Milligan (2001), Evans (2004) and Christensen and Knight (2015). Although outside the scope of this study, providing and wanting to care tends to be one of the ‘humanistic’ or ‘altruistic’ qualities that attract men into nursing.
What is evident in the literature is that male nursing students face the same discriminatory practices as their male registered nurse colleagues (Wilson, 2005; Kouta and Kaite, 2011; Christensen and Knight, 2015; Christensen, 2017). However, what is less evident is at what point in the curriculum or their nursing education they begin to experience these. The available evidence is not very precise or specific because research into the experiences of male nursing students does not isolate the data between first year, second year and so forth. It appears that the literature reflects a collective male nursing student voice, so it is possible that the experience may be diluted by that of second and third year students, presumably as a result of clinical placement experiences. Therefore, there is very little evidence of the experiences of first-year male nursing students in particular as to whether they experience gender-role conflict or a smoother, easier transition into the nursing programme.
Aim
The aim of this exploratory study was to further understand the attitudes and perceptions of inclusivity in first-year male nursing students during their undergraduate nursing programme.
Methods
Setting
A total population sample of 22 first-year undergraduate male nursing students who were enrolled in a Bachelor of Nursing degree programme at a metropolitan new university in southern England were approached to take part in the study. The university had recently acquired accreditation to teach the undergraduate nursing programme and therefore the participants in this study were the first cohort enrolled. The school of nursing adopted twice-yearly intakes, in January and September. The male nursing cohort was designated into two groups dependent on their enrolment into the nursing programme. Group 1 students (BN 1, n=9) were students who commenced in January and group 2 those who started (BN 2; n=13) in September.
Recruitment
The first-year male nursing students were emailed through the university's student group email system. The email contained an introductory covering letter inviting them to participate in the study. Attached was a participant information sheet that provided more detailed information about the study, including confirmation of ethics clearance. Consent was assumed on the basis of the student completing the questionnaire and returning it to a specified member of the research team. Students were assured that participation in the study was entirely voluntary and that there would be no institute-related repercussions if they chose not to participate. A 64% response rate was achieved (n=14).
Data collection
A Likert scale survey was used in this study. The first-year male nursing students' experiences of undergraduate nursing education was assessed using the Inventory of Male Friendliness in Nursing Programs (adapted for demographic data), which measured those experiences related to general recollections of the undergraduate nursing programme and opinions and beliefs about gender-specific issues as they relate to nursing education. The 22-item Likert scale (1=strongly agree to 5=strongly disagree) (or reversed where questions are framed as negative) has a good level of internal consistency, with a reported Cronbach's alpha of 0.84, and has been shown to reliably identify gender-based barriers in male nurses (O'Lynn, 2004). In addition, the 37-item Gender Role Conflict Scale (O'Neil, 2015) was used to ascertain whether first-year male students experienced challenges with personal gender-role attitudes, behaviours and conflicts. The scale has a high level of internal consistency with a reported Cronbach's alpha of 0.73-0.91; test-retest reliability range of 0.72-0.86 (O'Neil, 2015).
Inventory of Male Friendliness in Nursing Programs
This 22-item Likert scale questionnaire elicits information from male nursing students as to their experiences in the nursing programme. It covers three domains. First, it asks for demographic data and prior experiences of being cared for or having contact with male nurses in other professional capacities. The second domain assesses the male student nurses' experiences of the nursing programme, for example: ‘Most of my nursing lecturers referred to the nurse exclusively as “she”’ or ‘My nursing programme included content on a number of men's health issues’. The final domain looks at the students' perceived or actual barriers they experienced during their education, for example: ‘As a male student, I was nervous that a woman might accuse me of sexual inappropriateness when I touched her body’, or ‘In my nursing program, male and female students were treated more differently by the lecturers than I had originally anticipated’. Low scores on this scale suggest male students feel unvalued in the nursing programme (O'Lynn, 2004).
Gender Role Conflict Scale
This 37-item Likert scale is used to assess men's fear of femininity in themselves. It focuses on 4 factors: success, power and competition (behaviours that exemplify substantiating value and overaccomplishment); restrictive emotionality (the inability or difficulty in expressing feelings); restrictive emotional behaviour (limited ways of expressing sexuality); and conflict between work and family relations (difficulty in maintaining a healthy lifestyle). High scores on this scale denote gender-role conflict (O'Neil, 2015).
Data analysis
Quantitative data were analysed using descriptive statistics along with non-parametric measures using the Mann-Whitney U test to elicit differences between the two groups of first-year male nursing students (January versus September). Mann-Whitney is generally used when the sample size between each group is not evenly distributed; it is used to compare the ranked scores between the groups. In other words, group A's scores are different to group B's scores and, when calculated, should ideally demonstrate a statistical difference between the groups. Means and standard deviations were calculated for the demographic data along with the two scales used.
Ethical approval
A low-risk ethics approval was sought and granted by the university's human research ethics committee (approval number SFEC-2017-089).
Results
The survey was separated into four categories: demographic data, experiences of male nurses, male nurse friendliness of the programme and gender-role conflict (which can be further subdivided into four subcategories: success, power and competition; restrictive emotionality; restrictive affectionate behaviour between men; and conflicts between work and leisure).
Demographic data
This section of the survey asked the respondents four questions relating to their age, occupation prior to entering the nursing programme, cultural heritage and marital status. The mean age of respondents was 22 years, with 57% of them having had previous healthcare experience; 71% were single (Table 1).
Table 1. Male student nurse demographics
| Demographics (n=14) | Frequency | % |
|---|---|---|
| Age (years) | ||
| 18–20 | 3 | 21 |
| 21–25 | 5 | 36 |
| 26–30 | 4 | 29 |
| 31–35 | 2 | 14 |
| What was your occupation before coming into the nursing programme? | ||
| Healthcare assistant | 8 | 57 |
| Student | 3 | 21 |
| Retail | 2 | 14 |
| Military | 1 | 7 |
| How would you describe your cultural heritage? | ||
| White | 10 | 71 |
| Black | 1 | 7 |
| Asian | 3 | 21 |
| What is your marital status? | ||
| Married or de facto or domestic partnership | 4 | 29 |
| Single or single never married | 10 | 71 |
Experiences of male nurses
The respondents' prior experiences of contact with a male nurse were limited. Although 50% had stated that they had no previous experience of male nurses, 57% said that they or a significant other had been cared for by a male nurse (Table 2). What is of interest is that more than 28% suggested that more men in the profession would increase diversity and 21% suggested it would reduce the stigma associated with being a nurse who is male. Of note is that 21% stated that having more men would not change anything. When asked where they would like to work once qualified most respondents identified acute adult care (29%) and critical care environments (29%).
Table 2. Respondent experiences of male nurses
| Frequency | % | |
|---|---|---|
| Did you have male lecturers/tutors while you were a nursing student? | ||
| Yes | 14 | 100 |
| No | 0 | 0 |
| Prior to coming into the nursing programme, had you or a significant other ever received care from a nurse who was male? | ||
| Yes | 8 | 57 |
| No | 6 | 43 |
| Prior to coming on the nursing programme, had you ever personally known a male nurse? | ||
| Yes | 7 | 50 |
| No | 7 | 50 |
| Knowing what you now know of nursing would you have started your nursing education? | ||
| Yes | 14 | 100 |
| No | 0 | 0 |
| What was most important driver for you when deciding to become a nurse? | ||
| Caring or compassionate reasons | 11 | 79 |
| Job opportunity or employment reasons | 1 | 7 |
| Personal satisfaction | 1 | 7 |
| After graduating, which area of nursing are you most interested in working? | ||
| Acute care adult | 4 | 29 |
| Emergency/intensive care unit | 2 | 14 |
| Oncology/palliative care | 1 | 7 |
| Operating theatre | 2 | 14 |
| What experiences had you had of male nurses prior to starting the nursing programme? | ||
| None | 7 | 50 |
| Friend or family member is a male nurse | 1 | 7 |
| Healthcare setting as a patient | 2 | 14 |
| Healthcare setting as a student or colleague | 4 | 29 |
| Given the opportunity, what would you say to other men about starting a career in nursing? | ||
| Encouragement | 8 | 57 |
| Get experience first | 1 | 7 |
| A good job/career | 3 | 21 |
| Did not answer | 2 | 14 |
| If there were a higher proportion of men in nursing, what impact do you think that would have on the profession? | ||
| Being supportive | 1 | 7 |
| No change | 3 | 21 |
| Reduce stigma | 3 | 21 |
| More men in the profession | 2 | 14 |
| Increase diversity | 4 | 29 |
NB The numbers and percentages do not all add up to the total number of respondents
Inventory of Male Friendliness in Nursing Programs
The mean score obtained from the 22-item scale suggested the respondents held favourable views towards nursing and the nursing programme (mean 2.54). It is evident that there are areas of hidden advantage for these students, for example, 28% of respondents had been told that they would easily secure employment once they finished because of their gender and 57% were encouraged to pursue leadership roles (Table 3). There were a number of students who were genuinely concerned that their touch and/or nursing care might be misconstrued by female patients as being sexual (57%).
Table 3. Perceived Inclusivity in the nursing programme
| % Agreeing* | Mean score† | SD | |
|---|---|---|---|
| Most of my nursing lecturers referred to the nurse exclusively as ‘she’ | 7 | 2.79 | 0.893 |
| My nursing programme included a historical review of the contributions men have made to the nursing profession | 7 | 0.93 | 0.997 |
| My nursing programme actively recruited men to enrol as students | 57 | 2.57 | 1.089 |
| There were times in class when nursing lecturers made disparaging remarks about men | 14 | 3.43 | 1.089 |
| My nursing programme included content on a number of men's health issues | 50 | 2.36 | 0.929 |
| I have been provided opportunities to work with male nurses during my clinical placements | 29 | 2.21 | 1.051 |
| I felt able to make long-lasting working relationships with other male nursing students while in the nursing programme | 64 | 2.86 | 1.292 |
| My female colleagues expected more work from me during groupwork | 21 | 2.86 | 1.167 |
| Many believe that men and women have different communication styles | 43 | 2.00 | 1.414 |
| My nursing programme discussed how to overcome communication differences to ensure good therapeutic and working relationships | 86 | 2.86 | 1.099 |
| My nursing programme encouraged me to strive for leadership roles | 57 | 2.79 | 1.188 |
| My lecturers provided me, as a man, guidance on the appropriate use of touch | 36 | 2.00 | 1.109 |
| My nursing programme encouraged me to connect with other male students for peer support | 43 | 2.29 | 0.914 |
| People most important to me were supportive of my decision to enrol in the nursing programme | 93 | 3.57 | 1.089 |
| I felt I had to prove myself in my nursing programme because people expect nurses to be female | 36 | 1.93 | 1.141 |
| In my nursing programme, male and female students were treated more differently by the lecturers than I had originally anticipated | 29 | 3.07 | 1.141 |
| My gender was a barrier in developing collegial relationships with some of my lecturers | 7 | 3.29 | 0.914 |
| As a male student, I felt welcomed by most nursing staff during my clinical placements | 36 | 2.50 | 0.941 |
| As a male student, I was nervous that a woman might accuse me of sexual inappropriateness when I touched her body | 57 | 1.00 | 1.092 |
| My nursing programme prepared me well to work with primarily female co-workers | 50 | 2.50 | 1.225 |
| I've been told I'll get a job after graduating because I'm a man | 29 | 2.29 | 1.267 |
The lower the mean, the less male friendly the nursing programme is perceived to be SD=standard deviation
In this study, internal reliability of the male nurse friendliness scale reported a Cronbach's alpha of 0.720, indicating an acceptable level of internal consistency (Cohen and Swerdlik, 2017). To compare the difference between the January and September cohorts a non-parametric Mann Whitney U was performed and indicated that male inclusivity in the undergraduate nursing showed no significant statistical difference (U=21, P=0.755, r=-0.106).
Gender-role conflict
The overall mean gender-role conflict score was 2.78. Given that the higher the mean the more conflict being experienced, this suggests that the men in this study experienced some degree of gender-role conflict. When the four subsets associated with the scale were analysed, success, power and competition (mean 3.30) and work and leisure conflicts (mean 3.39) were higher than the other two subsets with restrictive affectionate behaviour between men scoring the lowest (mean 2.04).
These results suggest that personal achievement is a major determinate in successfully completing the nursing programme. Some 85% of respondents identified that climbing the career ladder and doing well were important factors for them (Table 4). When it came to feeling superior to others this response scored lowest (mean 1.93). Restrictive emotionality (mean 2.40) and restrictive affectionate behaviour between men (mean 2.04) scored low, which suggests that the respondents felt comfortable being emotionally and physically close to their peers and men in general (Table 4). Although work and leisure conflicts also scored high this could equally apply to female students.
Table 4. Feelings of gender-role conflict
| % Agreeing* | Mean score† | SD | |
|---|---|---|---|
| I worry about failing and how it affects my doing well as a man | 36 | 3.36 | 1.692 |
| I have difficulty expressing my emotional needs to my partner | 0 | 2.00 | 0.877 |
| Men who touch other men make me uncomfortable | 0 | 1.21 | 0.426 |
| Finding time to relax is difficult for me | 50 | 3.43 | 1.651 |
| Doing well all the time is important to me | 86 | 4.64 | 1.151 |
| I have difficulty expressing my tender feelings | 14 | 2.57 | 1.016 |
| Hugging other men is difficult for me | 0 | 1.36 | 0.745 |
| I often feel that I need to be in charge of those around me | 29 | 2.93 | 1.328 |
| Telling others of my strong feelings is not part of my sexual behaviour | 36 | 3.36 | 1.277 |
| Competing with others is the best way to succeed | 21 | 2.50 | 1.092 |
| Winning is a measure of my value and personal worth | 14 | 2.57 | 1.342 |
| I often have trouble finding words that describe how I am feeling | 3 | 2.71 | 1.383 |
| I am sometimes hesitant to show my affection to men because of how others might perceive me | 36 | 3.14 | 1.791 |
| My needs to work or study keep me from my family or leisure more than I would like | 50 | 3.64 | 1.550 |
| I strive to be more successful than others | 57 | 3.57 | 1.604 |
| I do not like to show my emotions to other people | 14 | 2.57 | 1.089 |
| Telling my partner my feelings about him/her during sex is difficult for me | 21 | 2.29 | 1.139 |
| My work or school often disrupts other parts of my life (home, family, health leisure) | 43 | 3.21 | 1.369 |
| I am often concerned about how others evaluate my performance at work or school | 57 | 3.57 | 1.089 |
| Being very personal with other men makes me feel uncomfortable | 7 | 2.00 | 1.109 |
| Being smarter or physically stronger than other men is important to me | 21 | 2.36 | 1.151 |
| Men who are overly friendly to me make me wonder about their sexual preference (men or women) | 14 | 2.43 | 1.342 |
| Overwork and stress caused by a need to achieve on the job or in school, affects/hurts my life | 29 | 3.14 | 1.292 |
| I like to feel superior to other people | 0 | 1.93 | 0.730 |
The higher the mean, the more gender-role conflict is present SD=standard deviation
In this study, as with the Inventory of Male Friendliness in Nursing Programs, internal reliability of the Gender Role Conflict Scale reported a Cronbach's alpha of 0.868, indicating a good level of internal consistency (Cohen and Swerdlik, 2017). To compare the difference between the January and September cohorts a non-parametric Mann Whitney U test was performed and indicated that gender-role conflict showed no significant statistical difference (U=18, P=0.491, r=-0.207).
Discussion
The aim of this study was to understand the experiences of first-year male nursing students as they entered the undergraduate nursing programme. Using the Inventory of Male Friendliness in Nursing Programs and the Gender Role Conflict Scale, it is evident from the data that the male first-year nursing students at this university had acclimatised into the nursing programme despite the reported challenges that male nursing students often experience (Christensen, 2017).
It would appear that many first-year male students have not faced the realities of clinical practice, which might be a contributing factor. Christensen and Knight's (2015) study, for example, described some difficulties their male nursing students had while on clinical placement; one student being escorted off the premises of a girls' high school for not having a chaperone and his presence on the school campus being regarded as unacceptable. In Christensen's (2017) study male nursing students were excluded from providing care.
The perceptions of these male students with regard to touch or care were not too dissimilar to Wilson's (2005) and Isaacs and Poole's (1996) early work, in which male students were concerned their care might be perceived as sexual. Interestingly, the barriers experienced by male nursing students from these studies centred on the clinical environment and although not examined specifically in this study, one group (January commencement) had already experienced a clinical rotation. Therefore, although there was no indication of any perceived or actual difficulties experienced by the January group respondents in this study, it is possible that clinical placement may have had an effect on the perceptions of male nursing students and perhaps this is a reflection of the barriers that other studies allude to (O'Lynn, 2004; Dyck et al, 2009; Meadus and Twoomy, 2011).
Gender-role conflict was not an appreciable concern for these students. Although there was the suggestion that power and competition figured highly in the students' responses, for example progressing in their career, striving to be successful and doing well, there was the implication that failure either as perceived by others or internally felt was something that should be avoided. However, what was more illuminating were the responses where feeling comfortable around men in a nurturing and empathic way did not cause these students any concern. This is different to that reported in the literature where some male nurses felt they had to overexert behaviours of heterosexuality so as not to be stigmatised as something different, sexually or otherwise (Harding, 2007; Harding et al, 2008; Fisher, 2011). In using the BEM Sex-Role Inventory, Fisher (2011) for example, found that most male nurses possess ‘feminine’ characteristics essential for nursing despite the sex-role stereotyping that often accompanies the image of a male nurse as one of effeminacy and homosexuality. Yet the men in this study showed no discomfort at the prospect of closeness with another man; the degree of closeness was beyond the scope of study and therefore it is difficult to discern the deeper connotation of those statements associated with this: ‘hugging other men is difficult for me’, ‘men who touch other men make me feel uncomfortable’ or ‘verbally expressing my love to another man is difficult for me’.
Implications for education and practice
It would appear from these data that assimilation into the nursing programme for first-year male nursing students does not generally lead to gender-role conflict. However, some of the barriers experienced by other male nursing students further along their nursing education appear to be of significance. The responses seem to indicate that the nursing curriculum and its delivery in the very early stages of male nursing educational experience are both extremely supportive. Therefore, further research into this area could include a longitudinal study looking at different year groups of male nursing students and their perceptions of gender-role conflict over time. Another area for research would be a comparative study looking at the Inventory of Male Friendliness in Nursing Programs, the Gender Role Conflict Scale and the Belongingness Scale—Clinical Placement Experiences (Levett-Jones et al, 2009) to ascertain if clinical placement experiences brings about a perceptual change in the nature of nursing for men..
Limitations
Sample size was one of the major limitations of this study and this is possibly reflected in the lack of statistical significance. Although the 64% response rate is a positive point, the small number of student responses makes it difficult to generalise to a total population of first-year nursing students. However, the authors were conscious of the exploratory nature of this study given the evidence of male nursing student experiences and perhaps consideration should have been given to producing a greater cohort size by including students from other higher education institutes.
In addition, consideration had not been given to the international perspective, especially where cultural sensitivities and intersexual propriety need to be observed. One option would have been to use the Belongingness Scale—Clinical Placement Experiences to ascertain pre- and post-data to compare the male friendliness and gender-role conflict against clinical practice. However, this was impractical because at the time there was only one group that had been on clinical placement (January cohort) and therefore attempting to compare results between these two groups may have skewed the results significantly.
Conclusion
Although there is some suggestion in the literature that male nursing students experience some of the same types of discriminatory/inequitable practices as their registered colleagues, these types of behaviours were not apparent in this study. However, what is less evident in the literature is at what point in their nursing education these practices may become more noticeable. It is noteworthy that those studies reporting discriminatory/inequitable behaviours among male nursing students tended to involve those in the latter part of their nursing education. Therefore, it appears that length of time in the nursing programme, along with the reality of clinical practice, may be contributing factors and consequently may have changed male nursing students' perceptions of nursing generally. However, the participants in this study certainly bore no ill feelings towards their nursing education and saw the programme as being very inclusive and accepting of them.
KEY POINTS
- It has been reported that male nursing students experience the same types of discriminatory behaviours and practices as their registered male colleagues
- It is difficult to determine at what point in the male students' nursing education these behaviours and practices emerge
- First year male nursing students in this study reported feeling accepted and supported into the nursing programme
- The results suggest that gender-role conflict for these students at this stage of their nursing education is not an issue overall
CPD reflective questions
- The nature of touch is often seen as a challenge for men. How might this be mitigated to allow the therapeutic relationship to develop?
- The men in this study identified difficulty in communication between the genders. Think back on a situation in which there was an episode of miscommunication and how that might have been done differently
- The results from this study suggest that clinical placement might impact negatively on male nursing students. What strategies could be adopted to ease the transition for male nursing students coming to practice?